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Health Services Research & Development

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HSR&D In Progress

September 2021

In This Issue: Helping Veterans Cope with and Conquer Pain
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Optimizing Pain Management in End-Stage Renal Disease among Veterans

Feature Article

Takeaway: This study is expected to improve our understanding of the impact of VA initiatives to improve opioid safety on Veterans with serious illness. This will help VA ensure that these vulnerable Veterans are provided care that relieves distressing symptoms.

Over the past decade, VA has implemented opioid policies, most notably the 2013 Opioid Safety Initiative (OSI), designed to address the burgeoning opioid crisis. As the pendulum has swung away from opioid prescribing, it is possible that some patients with serious illness may have experienced unintended consequences, including uncontrolled pain, even while others may have avoided potential complications of opioid use. The potential impact of these policies on Veterans with end-stage renal disease (ESRD) – approximately 35,000 Veterans for whom balancing the benefits and harms of opioids may be particularly challenging – is unknown. With a limited life expectancy and a substantial pain burden, these Veterans are at increased risk of opioid-related serious adverse events (SAE), including opioid overdose. Yet compared with other seriously ill populations, they have fewer non-opioid analgesic alternatives to fall back on and may face barriers to non-pharmacologic pain management.

This ongoing study (July 2021 – June 2025) is the first to examine the impact of opioid safety initiatives and prescribing guidelines on a group of Veterans with ESRD. Leveraging VA data that include rich measures of pain control unavailable from any other national data source, investigators will:

  • Examine changes in pain management strategies, opioid-related SAE, and pain control among Veterans with ESRD between 2010 and 2018;
  • Compare changes in opioid-related SAE by the setting of dialysis (VA, VA-Community Care, Medicare) between 2010 and 2018; and
  • Elicit the perspectives and experiences of Veterans with ESRD – and the clinicians who care for them – related to pain management in the context of VA opioid safety initiatives.


The study employs a sequential explanatory mixed-methods design. The use of this design to triangulate quantitative and qualitative findings on pain management in the context of contemporary opioid policy is a novel contribution to the field of opioid research. The quantitative portion of the study includes Veterans on dialysis across all VAs between 2010 and 2018. Investigators will conduct an interrupted time series analysis of linked VA, Medicare, and United States Renal Data System (USRDS) data to examine whether Veterans with ESRD have had changes in pain therapies (opioids, non-opioids, non-pharmacologic), opioid-related serious adverse events, and pain, overall—and by setting of dialysis — over time since the 2013 OSI. Investigators will then conduct semi-structured interviews with Veterans with ESRD and VA clinicians who care for ESRD patients in order to identify opportunities for improvement in VA pain management policy and practice.


No findings to report at this time.

Anticipated Impact

Investigators will work with this study’s advisory board of operational partners to ensure that the results of this research inform policy about how to optimally align opioid safety initiatives and pain management guidelines to meet the needs of Veterans with ESRD, as well as those with other serious illnesses. They also will collaborate with the Board to develop a “roadmap” that summarizes key findings, explains implications for policy and clinical care, and identifies priorities for future clinical and policy interventions intended to optimize pain control for Veterans with ESRD. Further, this roadmap will likely be adapted for other groups of seriously ill Veterans.

Principal Investigator

Melissa Wachterman, MD, MPH, is a practicing internist and palliative care physician at the VA Boston Healthcare System – and an investigator with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Bedford and Boston, MA.

View study abstract

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